Unexpected Medical Encounters
It is likely that the CCITT eventually will be the first to arrive at a vehicle accident or medical emergency in the field. It is in the best interests of the CCITT to have a predesignated plan of action for these situations.
Policies should be developed for when the ambulance has a patient in transit, is on the way to pick up a patient, and is returning from a transport without another commitment. These policies should be made with legal input and should combine the employment and other jurisdictional requirements of the specific transport personnel and other participants in the process (eg, EMT driver).Because CCITT members might not have prehospital credentials as do EMTs, they should know whether their state's Good Samaritan laws protect on-duty health care professionals and whether they are required to stop and provide care. Many teams stop and provide emergency care as needed and simultaneously contact 911. The decision to do so when transporting a patient or en route to pick up a patient depends on multiple factors, including the status of the patient, the condition of the accident scene and victims, team policy, and the opinion of medical control, if applicable. The condition of the patient the CCITT has agreed to transport must be continuously monitored and care maintained regardless of any external situation and must remain the team's top priority. A poor outcome possibly linked to a delay in care or transport may be grounds for legal action (see Chapter 7).
A. Interfacing the EMS Transport of Pediatric Patients With CCITT “Scene Response”: In a changing health care environment, the most effective utilization of health care services may be to incorporate or combine transporting teams into one central transporting service (adult and pediatrics; adult, pediatric, and EMS; or pediatric and paramedicparamedic pediatric transport services [more for pediatric patients with greater technology needs]).
With combined pediatric and adult transport services, there is potentially or more likely direct interface between the CCITT services and EMS crews transporting a critically ill child. This combined system increases likelihood of the CCITT services to perform pediatric critical care scene response management. This is a new environment for the CCITT crew in terms of their knowledge base and inherent organizational system. A successful CCITT-EMS interface would include the CCITT becoming familiar with this EMS transport environment, training of the CCITT crew for EMS systems, CCITT understanding of the pediatric knowledge base by the EMS crews, and most importantly, understanding the experience of the EMS crew with pediatric criticallyill and injured patients. The CCITT crew must also be familiar with the environmental stresses that occur during these patient-EMS interfaces— cold, rain, terrain, and actual limitations of transferring the patient. This pediatric scene response is new to certain urban CCITTs, but certain CCITT services that transport over long distances or rural environments have become experts by trial and error in this type of transport.
B. Interfacing the EMS Transport of Pediatric Patients with CCITT Services: There may be variations of “EMS Scene Response.” In certain situations utilized by CCITT teams-whether ground, rotor-wing or fixed-wing services-the ability to transport these critically ill and injured neonates and or children may be limited because of availability of service capabilities or teams. In certain situations, this can be a limiting factor for optimizing transport for critically ill neonates and or child. In the realm of transport adaptability, flexibility, ingenuity, and thinking outside the box, many transport services have encountered these type of cases, and some of these particular patients are frequent participants. CCITT services must develop systems, pathways, or protocols for handling these types of particular pediatric or neonatal patient transfers.
The CCITT systems or services must develop an integrating process or protocol for the local or appropriate EMS services with the most appropriate transfer process for these patients to either a fixed referral center or a designated rendezvous point for the CCITT team to accept and transport these patients between the 2 services. In CCITT services that have long transport distances or are located in rural areas, these types of transports are common. They have developed a process integrating the local or most appropriate EMS services for these particular patients. These teams have developed or adapted this mode of pediatric/neonatal patient transfer very effectively.
The caveat in this mode of transport is that both the referral, local EMS services, and medical control of the CCITT services must all be in mutual agreement that this is the most optimal transfer process for this particular patient. These particular pediatric or neonatal transports must be individualized, emphasizing the best care for the child while using the most efficient transporting process or integration of services that shortens transfer time while improving overall survival with decreasing morbidity and mortality. These types of transports should be part of any CCITT services that deals with rural areas or limited access capabilities by referral centers for these types of pediatric/neonatal patients. The philosophy of EMS just transporting this particular patient because of the inability of CCITT to immediately transport will, in a majority of cases, be the best optimal process. In this new health care environment with increasing survival rate for the neonatal and pediatric patients with complex diseases and special high-tech requirements, these types of EMS services can be taxed or limited. The knowledge base or expertise, equipment needs, or vehicles by local EMS that is required to transport these particular “high-tech or specialized” pediatric or neonatal patients may be very limited to none; therefore, CCITT involvement is strongly encouraged in the patient discharge process and for continued care with the referral center.
The CCITT system must be constantly adapting and integrating these types of patients into their database of specialized patients, transfer process, and education with local EMS referral centers and have to provide medical control for these particular types of patients.Local, regional, or state disaster response plans of any CCITT service should include pediatric/neonatal pediatric transport protocols.
C. Key Aspects of the Interface Between the CCITT and EMS the “Scene Response Arena”:
1. Patient Handoff Environment Between EMS and CCITT: These
2 services need to come to a mutual understanding of the knowledge base and limitations of each service as well as their expectations. The CCITT team must have an extensive knowledge base for the various EMS crews with which they may interface, which will decrease missed communications, decrease patient handoff time, and improve efficiency of medical services rendered at the scene and overall decrease transport time. With improved CCITT understanding of the EMS services, the team will improve its critical thinking process for the anticipation and/or expectation of the medical needs/interventions that will be required for the patient.
2. Expectations Between the EMS and CCITT Teams: The major critical error in patient handoff is the lack of understanding or interpreting the level of care/experience between the 2 services. An understanding of the environment in a training level between the 2 services greatly reduces resuscitation needs and expectations, reduces unnecessary interventions, and improves overall patient outcome. The expectation between these 2 parties needs to be addressed in the initial phase of patient transfer. The CCITT's first interface with the EMS crew should be focused on a concise and brief chief complaint, the crew's initial assessment of the patient, situational or environmental factors, critical thinking of the EMS crew's assessment, interventions or therapeutic interventions with the resultant patient's response, and current cardiovascular status of the patient.
The CCITT must always be cognizant of the stress factors by the EMS crew. They must be respectful and courteous to the crew and commend the crew for their services. During the patient transfer or handoff, acknowledgment of the EMS services with positive feedback is encouraged. If issues occur during patient transfer, they should be addressed in a more appropriate environment and with appropriate educational needs by the teams. This process of patient handoff can be incorporated as part of the CCITT educational outreach services with the referring centers and EMS.Environmental Issues Affecting the Medical Response by Transporting Teams: The environmental factors can be weather related or terrain, patient access, or personnel limitations. These environmental issues necessitate the crew's alteration in critical thinking process and interventions. These environmental factors play a role in the mode of transport between these 2 services. Environmental factors could necessitate a rotor-wing base service utilizing a ground service to interface with an active EMS transporting service. This would necessitate an adjustment in CCITT method or mode of transport back to the accepting facility. Example: a rotor-wing team flies out to scene response activated by EMS crew, and weather changes prevents the helicopter return to the accepting facility. The solution would necessitate the helicopter team returning to the facility using the EMS service as a ground unit. In pediatric transport, as in the adult realm, using critical thinking processes in a changing transport environment is the key aspect to success.